It is a long-understood principle of healthcare to create and keep up to date and accurate records relating to the intake and care of patients. Traditional systems rely on hand-written records kept by caregivers. For example, a hospital or clinic might have paper forms that were set up by an administrative intake staff member and which identify the name, age, and gender of the patient, and perhaps the symptoms and appearance of the patient. A physician would then use the form to write thereon further comments, diagnoses, and recommended actions according to the observations, testing, and conclusions of the physician. A file and its content would be created into which the form was placed. The file, archived by patient name or other identification number, would become a permanent patient record that could be referenced at a later date if the patient returned for other checks or treatments.
A paper copy of a patient medical record requires significant, and often expensive, space in which to store the file. It is difficult and expensive for a hospital that sees thousands of patients a year and which desires (or is required) to keep and archive the files to do so. File storage is therefore a logistical challenge and a real expense to all hospitals and clinical organizations. Also, increasing insurance and regulatory requirements require keeping the patient records for a long time, perhaps even after a patient is cured, transferred, or is even deceased. In addition, regulatory and governmental laws include requirements to protect patient privacy, and therefore the keeping of patient records is complicated by the need to keep the records safe and private, and the possibility of losing the same.
As to backing up the information in a traditional medical record, a photocopy of the physical patient file could be created from time to time (with the attendant effort and cost) for purposes of backing up the information. The original or backup copy may be stored off-site for safekeeping. Copies for insurance reimbursements, patient copies, or copies to be provided to another medical facility or care giver may also be reproduced, at a cost approximately linearly relating to the number of copies made. This copying and backup process is prone to the usual frailties of handling paper files and records, including the risks of loss of the original copies, the risks of misplacing documents in the wrong file, the risks of fire, flood, or theft, and so on. Also, the keeping and updating of paper patient records leads to losses when one or more sheets of paper in the file become transposed or left out of the file during handling. These losses are usually permanent, and the information lost as a result cannot be re-created reliably or with accuracy. Furthermore, even if the patient record could be re-created, the recreation would not carry the proper authenticity of an original.
Therefore, as in other fields of art, medical records have seen a trend towards digital record keeping (in electronic file formats) to replace the traditional paper file keeping. This is especially so in the field of medical records where the requirements for documentation and the physically disparate locations of the entities needing the files continues to grow. As an example, we briefly examine the record keeping operation of a hospital Emergency Department (ED).
Traditionally, the ED may include a medical record form dispensing station where paper copies of standardized intake and medical record templates (specialized blank forms) are stored and kept. This situation is fairly common in modern hospitals in the U.S. The blank forms are provided by vendors, with some vendors' products gaining wide acceptance so that practitioners may be accustomed to certain types of standard emergency medical records forms. Companies such as Patient Care Technology Systems, Emergisoft and T-Systems provide such templates and related supplies to U.S. hospitals for use in their EDs.
The traditional paper-based ED medical record station is usually set up with slots or shelves in a special cabinet or shelving unit, each slot containing one kind of ED medical record form that the ED staff knows how to use. When supplies of one form run low, a vendor or a staff member of the ED brings in new blank copies, or makes copies from a file that can be printed on a printer, or makes photocopies of an existing blank copy. However, invariably, the supplies of blank ED medical record forms do run out, usually at a time when the need is high and the staffing is low, and these paper forms tend to become disorganized, and can be placed into the wrong slot in their dispensing station, and so on.
The ED medical record forms are sometimes organized by malady, body organ, or area of the body, including spaces for selecting standard responses or conditions and spaces for making brief notes. A patient complaining of some condition in a body organ or area is interviewed by a physician who fills in various information into that ED medical record form. When the physician is done filling the form, the filled form is then processed by the hospital staff, and may be sent to a data processing center for copying or scanning into an electronic database.
As an example, a patient with abdominal pain is admitted to the ED. The physician or a staff member is alerted to the patient's complaint and takes a copy of the abdominal pain related ED medical record from the dispensing station. The form assists the practitioners in their examination and diagnosis of the patient, and organizes the information discovered in the patient examination. The ED medical record form becomes part of the patient's medical record or file.
FIG. 1 illustrates a typical ED medical record form dispensing station at a well-run hospital. The station comprises a number of shelves that hold blank template forms as discussed above, each of which addresses a common or expected condition in incoming patients. It can be seen that the present paper-based forms can be an organizational challenge: to keep the forms in stock, to avoid transposition or accidental misplacement in the slots, and so on. Also, if the ED decides to add a new form or reorganize the placement of the forms, this requires re-building or re-organizing the shelving space to accommodate a new slot in the desired place, and then the staff need to be alerted to this change.
It has not been possible or practical so far to develop economical, reliable, effective electronic substitutes for certain types of medical records and files. Some attempts to digitize the intake and treatment records for hospital emergency rooms have been less than optimal. For example, in some cases, workers are required to carry about fragile and expensive equipment such as tablet computing devices onto which the intake and records are taken. This equipment is prone to failure, loss, breakage, and other hazards of portable electronic equipment in an emergency department (ED) environment. Also, if such equipment is compromised, it may allow unwanted access to or loss of sensitive patient and hospital data. Other examples require treating physicians to interview patients and then proceed to a location where a computer terminal is present. This can result in imperfect transfer and entry of information into a patient's records if the physician forgets an important detail during this transaction, or if the physician is distracted on the way to making the entry, which is a common occurrence in practical situations in busy EDs.
The present disclosure addresses this issue and provides a number of embodiments that are helpful in situations such as those described below and beyond.